As a Certified Insurance Agent for Covered California I am scrupulous when it comes to reading each question on the application for health insurance exactly as written, except when the Covered California application asks for the sex of the applicant. Instead, I ask for the person’s or dependent’s gender. Covered California should stop asking about a person’s sex and allow them to specify a gender.

California individual and family plan health insurance carriers have been combating fraudulent enrollment for open and special enrollment periods. Many of the health insurance companies have placed additional requirements on applicants to verify California residency. Unfortunately, enrollments through Covered California, which have virtually no verification of special enrollment eligibility, continue to be a source of high-cost claims from fraudulent enrollments.

Some Covered California consumers are receiving confusing letters stating they are either not eligible for health insurance or will be awarded no monthly tax credits for 2017. These letters are arriving after consumers have already successfully renewed their coverage or just enrolled for 2017 health insurance. The letters seem to be automatically generated in error as the consumer’s account still show enrollment with tax credits.

For most Covered California consumers there will be only one PPO health plan to select. Blue Shield is the only health insurance company participating in Covered California that will offer a PPO health plan in the major metropolitan regions of California. While the PPO plan design signals to consumers that they have some freedom to use out-of-network providers, the Blue Shield benefits may be very restrictive.

With just four Live Oaks (Quercus agrifolia nee) in my backyard, I will usually rake up 2 to 3 wheelbarrow loads of acorns every fall. Until I started reading about Maidu Native Americans that lived in the Granite Bay area of California, I hadn’t considered acorns as a food source. After I had documented numerous Native American acorn grinding-hole sites around Folsom Lake, I figured that I should try and prepare some acorn mush that was a staple of the Native American diet prior to the gold rush of the 1850s.

Under the new GOP presidency and congress Obamacare looks to be repealed and the replacement to emphasize Health Savings Accounts. The economic rationale for Health Savings Accounts (HSAs) is that when consumers pay for their health care out of the accounts, they will drive down the cost of health care by favoring the least cost procedures. Unfortunately, HSAs without price transparency for the consumer does nothing to bring lower prices or efficiency to the market place. HSAs in our current market place are just scams.

For individuals and families who do not qualify for the Covered California tax credits, there are some alternative off-exchange health plans that may save you money. Health plans offered off-exchange, or directly from the health insurance company, can have different plan design benefits than the standard benefit design available through Covered California. Not only are the rates for these non-standard benefit plans usually less, the design of the plan may save you and your family additional money.
Covered California sets the metal tier plan design for Qualified Health Plans (QHPs) that are eligible to receive the Advance Premium Tax Credit subsidy when enrolled through Covered California. These are the standard benefit designs. Health insurance companies also offer the standard benefit design plans off-exchange at the same rates. But many health insurance companies have created non-standard benefit design plans that also fall within the metal tier levels of Bronze, Silver, and Gold.
Because the non-standard benefit plans meet the actuarial level of the metal tier (Bronze 60%, Silver 70%, Gold 80%) their rates are fairly close to the standard benefit design plans. However, the health insurance companies have tweaked some member cost-sharing elements of the plans. For instance, a non-standard plan may have a higher deductible amount and lower copayments or coinsurance than a standard benefit plan. In addition to the lower premium rates, some of the lower cost-sharing benefits may actually be beneficial to some consumers who utilize different elements of a health plan. Some consumers are willing to accept a higher deductible if they receive lower copayments for offices, labs, or prescription drugs.
Here are a few of the non-standard benefit designs offered off-exchange from some of the health insurance carriers in California.
Anthem Blue Cross Bronze Pathway EPO/PPO* 6900
The Bronze 6900 has a $6,900 medical deductible versus $6,300 for a standard plan. But whereas the standard Bronze has only three office visits at a $75 copay, the Bronze 6900 has a $55 primary care office visits not subject to the deductible. Another benefit is going straight into Tier 1 and Tier 2 prescription drug copayments without meeting a pharmacy deductible. The Bronze 6900 might be great for someone who is generally healthy, can accept a high deductible amount, but needs to see their doctor on a regular basis and takes a couple of medications. It has the potential to save them some money over a Silver plan.
*Home address will determine if a EPO or PPO is offered in the region.
Blue Shield of California Silver Seven 3750
The Silver Seven 3750 has a $3,750 deductible versus $2,500 for a standard Silver plan. The Seven indicates the plan has $7 primary care office copays, $7 acupuncture visit copay, $7 Tier 1 generic drug copay, and $7 lab copay. The Tier 2 and 3 drugs also have a lower copay than standard Silver plan subject to the pharmacy deductible of $250. This plan would appeal to consumers who have frequent doctor office visits and labs to manage a chronic health condition, but are relatively healthy.
Kaiser Silver 70 HDHP HMO 2700/15%
The Silver 70 HDHP 2700/15% is H.S.A. (Health Savings Account) compatible with a $2,700 deductible. Like all of the High Deductible Health Plans, excluding preventive health care, nothing is covered until you meet the deductible. Most HDHP are Bronze plans and have a $4,800 deductible. In addition, the standard Bronze HDHP plans have 40% coinsurance after the deductible is met while the Kaiser Silver 70 2700/15% has 15% coinsurance. A major benefit with for a Kaiser H.S.A. plan is getting an accurate quote for health care services. Kaiser has a list of costs for the most common health care services and they are generally very reasonable compared to other hospitals. This plan should be considered by people who like the Kaiser model of health care, want the tax benefits of an H.S.A., but don’t want the higher $4,800 deductible of a standard Bronze HDHP.
Oscar Simple Bronze
The Oscar Simple Bronze plan is about as close to a major medical catastrophic plan as a person can get who does not qualify for the Minimum Coverage plans. The individual deductible is $7,150 and the only items that are covered are generic drugs at a $5 copayment. Oscar is an EPO so the member does have a selection of doctors and hospitals they can visit without a referral. The Simple Bronze is only offered in parts of Los Angeles County and all of Orange and San Francisco counties. For a 30 year old in those regions the Simple Bronze will still be slightly more expensive than the standard Bronze plans offered by Chinese Community Health Plan, Kaiser, L.A. Care, and Molina. This off-exchange plan would work for someone who is super healthy, never visits a doctor except for an annual physical (which is included at no charge), and can afford the $7,150 deductible in case of a major accident or illness.
Sutter Health Plus
Sutter Health Plus offers health plans in the greater Sacramento region and Bay Area. None of their plans are available through Covered California. However, the rates for the Sutter Health Plus HMO standard benefit design plans are very competitive. Virtually the only way you can get access to Sutter hospitals and doctors are with the Blue Shield plans. A Sutter Health Plus Silver 70 plan for a 40 year old in Sacramento County is $417.37, while Blue Shield PPO is $478.95. Sutter’s rates tend to be slightly higher than Blue Shield in San Francisco, but comparable in other areas around the Bay Area. If you are a fan of Sutter and their doctors, and don’t like the uncertainty that Blue Shield might drop Sutter facilities and doctors from their health plans, a Sutter Health Plan should be given serious consideration.
Western Health Advantage Silver 3600 H.S.A
The $3,600 deductible of the Western Health Advantage Silver 3600 HDHP is also the maximum out-of-pocket for the plan. Once the member has spent $3,600, all benefits of the health plan are covered 100% by WHA. Excluding preventive office visits which are $0 cost, the member is responsible for all the health care costs up to $3,600. That includes prescription medications. This plan would work for individuals and families who infrequently use health care services, but want the assurance that if something big happens; there will be a low maximum out-of-pocket amount.

For the first time in my life I can commiserate with people who are losing their livelihood because of a government action. Just as some workers have been displaced because the government outlawed a product, changed an environmental regulation, or enacted a trade deal that smothered their industry, I too am on the receiving end of government legislation that will decimate my income. If Obamacare is repealed and the subsidies that make health insurance affordable for millions of Americans ceases, I will lose 90% of my clients.

With the constant erosion of the commission structures to agents for enrolling consumers into health plans in California, many agents have expressed their desire to stop assisting individuals and families with enrollment into Covered California health insurance. There has been renewed talk of allowing agents to charge a consultation fee to make up for the dwindling commissions they earn from the health plans and insurance companies. However, if agents want to make a decent return for enrolling consumers into health plans they need to provide the service so many of them advertise. We need to move from order-takers to consumer advocates, and we need fair compensation for our services.

The open enrollment and renewal period for Covered California is fraught with peril if you need to make changes to your household such as a change to income. If you make adjustments for 2017 before you renew your coverage, the system thinks you are making changes for 2016. This could have the impact of placing household members into Medi-Cal.